ICD-10 Toolkit

Table of Contents

Overview of Changes & Risks Planning Timeline Conducting a Needs Assessment Forms Assessment Vendor Assessment Completing a Chart Audit

Provider Training Opportunities Sample Primary Care Super Bill

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Table of Contents Overview of Changes and Potential Risks

3

Impacts in a Physician Practice Seven Key Impacts to Documentation Implementation Timeline

6

25 Most Common Pediatric Diagnosis Codes

7

Using the GEMs Books

9

Forms Assessment

10

Sample Primary Care Super Bill

13

Vendor Assessments

14

Completing a Chart Review Process

15

Provider Training Options

16

Appendix

Overview of Changes and Potential Risks The October 1, 2014 transition to ICD-10 is a federal mandate and there are no further delays anticipated. Failure to comply with the transition can result in significant risks to physician practices. For example, the Center for Medicare and Medicaid Services (CMS) and other industry experts have predicted impacts that include: • • • •

Up to a 300 percent increase in claims denials Up to a 25 percent reduction in revenues at the time of transition. A 40 percent reduction in employee and provider productivity at the time of transition. Needing up to 90 days of cash on hand to cover any disruptions in cash flow during the transition.

But there are quality implications as well. Because referrals to specialists, the lab, radiology or the hospital often require patient diagnosis information having the wrong code, or a code that doesn’t support the medical necessity of the order could result in denials of authorizations and delays to patient care.

Bottom Line: ICD-10 is more specific In addition to expanding from 14,000 codes to 68,000 codes, ICD-10 differs from ICD-9 in structure and specificity, with four new chapters added to the code set. Major changes include: • •

3 to 7 characters, both alpha and numeric characters Laterality (right vs. left), location/site, type of encounter, type of healing, frequency, cause and contributing factors • Greater accuracy in terminology and reflects advances in medicine The new code set also accounts for tools such as the Glasgow Coma score for assessing altered mental status and concussions. Therefore, while providers are not expected to become coders, they do need to include more detail in their documentation to provide the necessary clues for coders to appropriately bill and receive reimbursement for the work the provider has done. The better the documentation, the smoother the transition.

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ICD-10 Impacts Everyone in a Physician Practice Best practices include the following: -

Physicians begin using new documentation principles at least 3-6 months in advance. Begin working with your forms suppliers well in advance – everyone else will need to change their forms too! Consider implementing a computer-assisted coding program to assist with the transition. Complete chart reviews early and create a monitoring program to promote adoption of new principles. Consider offering anatomy and physiology refreshers for coding, billing and clinical staff, so they are aware of the increased specificity of terms used in ICD-10. Begin changing order/referral forms to use coding terminology instead of codes to prevent denials. ADMINISTRATORS

PHYSICIANS & APPs - DOCUMENTATION: Be specific! - Code Training: For paper forms, be aware of changes

-

Vendor/Payor Contracts Budgets Training Plans Oversight of implementation Update billing reports to reflect code changes

LAB

NURSES - Forms: How does diagnostic information reflect ICD-10 changes? - Documentation: Be specific!

OTHER CLINICAL

- Documentation: Be specific! - Reporting: Health plans will have new requirements for ordering and reporting services.

- Super Bills: Reviewed, revised and reprinted - Coverage: Authorizations, referrals, health plan policies and limitations

FRONT OFFICE

BACK OFFICE - BILLING - Policies and Procedures: All payer reimbursement policies must be reviewed. - Training: Billing department must be trained on new polices and the ICD-10 Code Set.

Information Provided by AAPC

BACK OFFICE - CODING

- Forms, Policies & Procedures: Be aware of new changes - Systems: Updates to systems that may impact productivity

- Code set: Comprehensive training – consider certifying non-certified coders. - Clinical Knowledge: Need to have more detailed info on anatomy & physiology and when to ask for more information from providers. - May need to code in both sets near transition.

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The Seven Key Impacts to ICD-10 Documentation While the transition can be daunting, the majority of the changes reflect a set of core basic documentation principles. In fact, just by including whether the injury or illness is on the right side or left side generated thousands of the new codes. So making sure you and your team are capturing that information is critical to a successful transition.

Remember: Not all conditions require all seven documentation principles, but these are simply the ones that appear most often in the ICD-10 code set.

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International Classification of Diseases 10th Revision (ICD-10) Are you ready?* The deadline for transitioning to ICD-10 is Oct. 1, 2014. Don’t wait to start this important process.

Complete between October – December 2013

Description

Owner

Start Date

Due by

Completed

Select internal Champion and/or committee. Set a schedule for project meetings (hard and firm dates and times). Identify and list all work processes and systems that utilize ICD-9 today. Conduct inventory of current coding tools/resources. Become familiar with ICD-10. Obtain code set and guidelines (electronic files available from http://www.cdc.gov/nchs/icd/icd10cm.htm). Research ICD-10 training. Research training programs/resources (e.g., online courses, local or regional seminars). Determine level of staff training needed by role (comprehensive, intermediate, or basic). Review status of and impact to electronic systems (see AAFP ICD-10 Systems Checklist). Appoint staff to act as primary/secondary contact with system vendors. Identify costs for temporary help or overtime cost during training and go-live. If using an outside source for coding and/or billing, learn vendor’s ICD-10 implementation plan. Budget – Identify ICD-10 related internal costs (see AAFP Cost Calculator www.aafp.org/icd10)..

October 2014 and ongoing

September 2014

Complete between April – August 2014

Complete between January – April 2014

Introduce concept and plans for ICD-10 to staff. Evaluate current cash flow (age of account balances, billing lag time). Set goals and plan to correct and prevent recurring errors/issues and optimize cash flow. Determine impact, if any, on quality initiatives (e.g., PQRS, EHR). Should 2014 reporting

be completed prior to system upgrades?

Complete ICD-10 training at all levels. Follow-up with electronic system vendors. Are upgrades completed or scheduled? Is training on upgraded system necessary and if so, scheduled? Note payer news regarding ICD-10 claims testing requirements/opportunities. Review insurance contracts for diagnosis-based payment impact (if any). Revise/develop/purchase internal coding resources (encounter forms, coding quick references) Re-evaluate cash flow (Are goals met and current processes efficient?). Review budget for any changes and accuracy. Consider opening a line of credit to offset potential cash-flow disruption. Review and ensure that physicians and coers have completed training. Test ability to apply ICD-10 codes to documentation as a training exercise. Do coding resources support efficient and accurate coding? Follow up with system vendors and/or outsourced business partners. Complete internal testing. Investigate options for external testing with clearinghouse/payers. Review and update contact information for support services. Review payer ICD-10 communications (include non-covered entities such as worker’s compensation). Watch for and disseminate ICD-10 changes in payment policies (e.g., Medicare local coverage decisions). Develop and assign workflow and processes effective 10/01/14. Verify that all testing was successfully completed. Consider direct-to-payer or other alternative claims submission resources (if testing has not been successful). Monitor payer news regarding readiness and changes to payment policies. Monitor all claims acknowledgement (997) and acceptance/rejection (277) reports Promptly correct and resubmit all rejected/denied claims. Evaluate post-implementation cash flow until claims filed with ICD-10 are consistently paid. Evaluate need for contingency activities (e.g., overtime, consultant, credit line). Monitor payer news regarding claims adjudication issues and resolutions. Monitor reimbursement accuracy and timeliness of payer per contract. Conduct coding review for accuracy and compliance.

*This timeline is a generalized resource from the AAPC for use in creating an individualized timeline specific to the needs of your practice. Successful ICD-10 transition may require different approaches based on practice size and resources.

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25 Most Common Pediatric Diagnosis Codes (From AAP Coding Newsletter)

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Using the GEMS Book While the General Equivalency Mappings or GEMs are useful tools in helping practices prepare for the ICD-10 transition, they are not substitutes for learning how to use the ICD-10-CM code sets. Mapping simply links concepts in the two code sets, without consideration of the context of specific information, whereas Coding assigns the most appropriate code based on documentation and applicable coding guidelines. Children’s Healthcare of Atlanta has provided the ICD-10-CM Mappings book to assist practices in the following: • Translating lists of codes, code tables and other coded data • Converting a system or application containing ICD-9-CM codes • Creating applied mappings between code sets • Studying the differences in meaning between the ICD-9-CM and ICD-10-CM systems Mapping Considerations ICD-10-CM is more specific and users of the GEMs mapping books should be aware of the following:

In addition, practices need to be aware of how the codes work with forward and backward mapping.

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ICD-9 Code

Description (Source)

ICD-10 Code

Description (Source)

493.9

Asthma, unspecified

J45.909 J45.998

Unspecified asthma, uncomplicated Other asthma

ICD-10 Code

Description (Source)

Best Practice Alert Use caution when mapping unspecified codes! Unspecified codes are more likely to result in denials of claims, especially when the new coding has more specific availability of codes.

J45.20 J45.21 J45.22 J45.30 J45.31 J45.32 J45.40 J45.41 J45.42 J45.50 J45.51 J45.52

Mild intermittent Uncomplicated Acute exacerbation Status asthmaticus Mild persistent Uncomplicated Acute exacerbation Status asthmaticus Moderate persistent Uncomplicated Acute exacerbation Status asthmaticus Severe persistent Uncomplicated Acute exacerbation Status asthmaticus

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Forms Assessment Checklist Task

Accountable Status

1. Collect your practice’s or department’s forms and identify who “owns” the form. Forms include: • Clinical forms with physician, advanced practitioner, nursing or other documentation • Charge entry and Super bills • Parent-completed forms (such as patient intake, history, etc.) • Web-based forms • Plans of Care and Discharge summaries • Progress Notes • Downtime Forms 2. Review the forms to look for ICD-9 codes or fields that capture: • Chief complaint, reason for visit or diagnosis description • Past medical history • Reviews of systems • Physical exam • Social and Family history • Impression or plan of care • Problem lists 3. Identify top diagnoses used in your department in ICD-9. 4. Verify current codes are accurate and your most commonly used codes. 5. Crosswalk the top codes to new codes in ICD-10 using your mapping book. 6. Review recommended changes with clinical teams, then submit updates to your forms vendor so changes are implemented prior to go-live. Determine whether the forms require translation into Spanish.

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Tax ID: #: 58-2201217 Billing Address: Sample ICD-10 POB 102709 Atlanta, GA 30368 Primary Care 404-929-8400 OFFICE SERVICES Office Visit Problem-Focused Expanded Prob. Focused Detailed Comprehensive Comprehensive-High Nurse Visit Only

Compliant Super

HEALTH CHECKS Under 1 year 1to 18 years 18 – 39 years

NEW 99381 99382 99383 99384 99385

EST 99391 99392 99393 99394 99395

FEE ____ ____ ____ ____ ____

E & M code with procedure(S) use modifier on E & M

Labs w/HC

PROLONGED SERVICE CPT FEE First (30-74 mins) 99354 ____ Each Add’l 30 minutes QTY____ 99355 ____ SCREENINGS CPT NML ABN ICD-10 ICD-10 Vision Screen 99173 Z01.00 Z01.01 ____ Hearing Screen 92551 Z01.10 Z01.118 ____

HgB U/A Z13.88 Z11.1

85018 81002 36415 86580

____ ____ ____ ____

Bld Lead (send out) PPD (TB skin test) INJECTIONS IM Diagnostic/Therapeutic Injection 96372 PROCEDURES ICD-10 CPT FEE Nebulizer or MDI tx Qty___ 94640 ____ Neb/MDI teaching 94664 ____ Burn; 1st Deg – Initial Tx 16000 ____ Burn – drsg/debride sm. 16020 ____ Cath-Straight; urethra 51701 ____ Cerumen Rem (1or 2) 69210 ____ Cautery (silver nitrate) 17250 ____ Drng – finger abscess 26010 ____ FB Rem. Skin; simple T07 10120 ____ FB Rem. Ear Canal T16.____ 69200 ____ Left __ Right__ ____ Encounter_______ FB Removal/Nose T17.____ 30300 ____ Sinus ___ Nostril___ Encounter____ Enter “VISIT/NC” for each visit ________________ FF – For Facility Fee ____________________

Sports/Camp Physical LABS (IN-OFFICE) Blood Glucose/Monitor Hemoglobin Stool Occult Blood Rapid Strep Screen UA Dip Urine Pregnancy LABS (SENT OUT) Specimen Handling

CPT NEW 99201 99202 99203 99204 99205

ICD-10 Z02.5

Healthcheck Normal Findings ___ Abnormal Findings ___ NB36 mos.) Meningococcal MMR Pediatrix Pentacel Polio-IPV PREVNAR Rotarix Rotateq TdaP Varicella PROCEDURES

Heel Stick I&D Abscess; simple sgl Nursemaid elbow reduct Spirometry Splint applic; finger Tympanometry Venipuncture IV therapy only when IV started Venipuncture/Nurse Venipuncture/MD >3 years old Venipuncture/MD